MEDICARE: FLORIDA DENTAL PROFESSIONALS, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1811548407
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA DENTAL PROFESSIONALS, P.A.

Provider Business Mailing Address
First Line	:	390 4TH ST N STE 101
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33701-2802
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	390 4TH ST N STE 101
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33701-2802
Country	:	US
Telephone Number	:	737-282-1980
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	TABATHA LEMKE
Credential	:
Telephone Number	:	217-540-6078

Provider Enumeration Date	:	09/25/2019
Last Update Date	:	11/09/2020

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